Provider Demographics
NPI:1306509302
Name:NUCKOLS, ELLIOT COLE (MPS)
Entity type:Individual
Prefix:
First Name:ELLIOT
Middle Name:COLE
Last Name:NUCKOLS
Suffix:
Gender:F
Credentials:MPS
Other - Prefix:
Other - First Name:BREANNA
Other - Middle Name:NICOLE
Other - Last Name:NUCKOLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 E 18TH ST UNIT 615
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-4094
Mailing Address - Country:US
Mailing Address - Phone:270-268-1835
Mailing Address - Fax:
Practice Address - Street 1:700 COMMERCE DR STE 250
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-5407
Practice Address - Country:US
Practice Address - Phone:270-268-1835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-16
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3675101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health